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Monday, February 4, 2019


Thank you to the State Board of Alaska for their commitment to me and how I practise pharmacy in the Last Frontier. Without communications such as this, I would have begun to think I was doing my job improperly. Now I know. I know how busy you are and appreciate your taking the time out of your schedule to hold me personally responsible for refusing to fill prescriptions. I find it odd that you didn't pop in to discuss the matter personally with me so I may have been able to share some insight from my location. I know, you're busy and the citizens of the state have the loudest voice.
Let me tell you a secret. It is our licenses on the line every day. It took years of training to achieve it and we shall not throw them away thanks to a veiled threat made by my State Board.
Seriously. Do you really believe we have not been exercising our professional judgement until this point? You say "We all acknowledge that Alaska is in the midst of an opioid crisis." 
How did we get here? By pharmacists filling everything unquestioningly or by us refusing to fill everything unquestioningly or by prescribers overprescribing and expecting pharmacists to fill everything? I wonder. . .
I take issue with this statement as well: "Yes, there is an opioid crisis. However, this should in no way alter our professional approach to treatment of patients in end-of-life or palliative care situations. Again, the fundamentals of using our professional judgment, skill and knowledge of treatments plays an integral role in who we are as professionals. Refusing to fill prescriptions for these patients without a solid medical reason may call into question whether the pharmacist is informed of current professional practice in the treatment of these medical cases."
This begs the question, Are you generalising about ALL refutations to fill opioids or just "end-of-life or palliative care situations"? Your opening statement makes it appear as if you are chastising us for "refusals to fill". Period. But this sentence is misleading.

If I am to understand this letter and its intent correctly, pharmacists are trying to limit the opioids dispensed. That's good, right?
Until citizens complain. Oh. I get it. That's bad.
Opioid control good until patients complain. Then Pharmacists bad.
Honestly, did you really write this next bullet point?

"3. Controlled substance prescriptions are not a 'bartering' mechanism. In other words, a pharmacist should not tell a patient that they have refused to fill a prescription and then explain that if they go to a pain specialist to get the same prescription then they will reconsider filling it. Again, this may call into question the knowledge, skill or judgment of the pharmacist." 
I don't like how you worded it but seriously, if the prescriber is ignoring our requests to get a patient into a Pain Management practise and insists on making therapeutic changes that are outside his area of expertise, then this is a good way to help the patient. (Yes, I have used my professional judgement to reach this point.)

Just out of curiosity, what has been done to empower the Medical Board to investigate bad prescribers?
I'm sure all of those pharmacists with whom you spoke, prior to the writing and distribution of this acerbic letter, would have at least one example each of a provider who is locally recognised as a bad egg. I'm also certain you could find cases where your professionally practising pharmacist abided by your second point: "This means that if a pharmacist has any concern regarding a prescription, they should attempt to have a professional conversation with the practitioner to resolve those concerns and not simply refuse the prescription.", only to be rebuffed or threatened by said prescriber or office. 

Since we are all making assumptions here, I am going to go out on a limb and assume you sent a similarly worded and threatening letter to the State's Prescribers. It is only fair since we are all on the same team. I am in fact positive that your bullet points resembled these: 
1. Prescribers must use reasonable knowledge, skill, and professional judgment when evaluating whether to write a prescription. Extreme caution should be used when deciding to write a prescription.  

2. Part of being a licensed healthcare professional is that you put the patient first. This means that if a pharmacist has any concern regarding a prescription, and they should attempt to have a professional conversation with you, the practitioner, to resolve those concerns you should immediately avail yourself to address their concerns and listen intently. Pharmacists being healthcare professionals also means that they have medication expertise to provide during that dialogue in offering advice on potential alternatives, changes in the prescription strength, directions etc. Simply refusing to listen to a pharmacist without trying to resolve the concern may call into question the knowledge, skill or judgment of the prescriber and may be deemed unprofessional conduct. 

3. As a professional reminder, failing to practice medicine using reasonable knowledge, skill, competence, and safety for the public may result in disciplinary actions under Alaska statute and regulation. Know when a patient's therapy is outside your range of practise and when to refer them to pain management or another professional with more expertise. 

4If in doubt, we always recommend partnering with the patient's pharmacist. Feel free to call her and discuss your patients. We are all licensed healthcare professionals and have a duty to use our knowledge, skill, and judgment to improve patient outcomes and keep them safe.

Don't forget to also attach the relevant laws of Alaska governing the medical practitioners so they can feel threatened. 

In summary, I would like to see the letter you sent to the Medical Practitioners about their prescribing habits and how you are strongly encouraging (or threatening, as you did to the pharmacists) them to work cooperatively with the pharmacists in charge of the patients of Alaska.
I would like to see how you are handling complaints of the pharmacists against rogue prescribers.
I would like to see an outline for how investigations are to be carried out against prescribers and their prescribing habits.

In order to be valid, a prescription must be issued for a legitimate purpose.
In order to be filled, it is my duty to verify this.
If I cannot verify it, I don't have to fill it.


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